What is the treatment for a scaphoid fracture?

Treatment of Scaphoid Fractures

The treatment of scaphoid fractures should be based on fracture classification as either undisplaced/stable or displaced/unstable, with undisplaced fractures managed conservatively using a short arm-thumb spica cast and displaced fractures requiring surgical fixation. 1, 2

Diagnosis and Classification

Before treatment, proper diagnosis and classification are essential:

1. Initial Evaluation:

   • Dedicated scaphoid views (carpal tunnel or semisupinated oblique projection) in addition to standard 3-view radiographic examination 1
   • Clinical Scaphoid Score (CSS) ≥4 indicates high probability of occult fracture 1
   • Initial radiographs may miss 20-30% of scaphoid fractures 1

2. Advanced Imaging for Suspected Fractures with Negative X-rays:

   • MRI without contrast is recommended as the next imaging study due to its high sensitivity for detecting occult fractures 1
   • CT without contrast is an alternative with 94.4% sensitivity and 100% specificity 1
   • Bone scan can be used if MRI is unavailable 1, 2

3. Classification:

   • Undisplaced/stable: no visible displacement on imaging
   • Displaced/unstable: >1mm fracture offset or dorsal lunate rotation on lateral view 3

Treatment Algorithm

For Undisplaced/Stable Fractures:

1. Conservative Management:

   • Short arm-thumb spica cast immobilization 2, 3
   • Wrist position of volar flexion with radial deviation is preferred 3
   • Duration: Typically 8-12 weeks or until radiographic union is evident

2. Alternative Option:

   • Percutaneous screw fixation is increasingly considered for non-displaced fractures to avoid prolonged immobilization 2, 4, 5
   • Particularly beneficial for athletes and those who cannot tolerate prolonged immobilization 5
   • Allows earlier return to activities and work

For Displaced/Unstable Fractures:

1. Surgical Management:

   • Open reduction and internal fixation (ORIF) with screw fixation is recommended 2, 4
   • For minimally displaced or reducible fractures, closed reduction and percutaneous fixation can be considered 2
   • Open reduction is recommended for all other displaced fractures 2

2. Post-operative Care:

   • Early mobilization after secure internal fixation 2
   • Possible use of playing splint for athletes after secure fixation 2

Special Considerations

1. Proximal Pole Fractures:

   • Higher risk of avascular necrosis due to tenuous blood supply 1
   • Operative fixation is generally preferred even if non-displaced 4

2. Surgical Approach Cautions:

   • During volar percutaneous fixation, be aware of potential injury to the flexor carpi radialis tendon and superficial volar branch of the radial artery 6
   • Consider a "mini-open" percutaneous approach to avoid damage to adjacent structures 6

3. Nonunion Management:

   • Undisplaced nonunions: Inlay bone graft using dorsal or volar approach 3
   • Displaced nonunions: Dorsal approach with internal fixation (particularly with radioscaphoid arthrosis) or volar approach with internal fixation 3
   • Immobilization for minimum 4 months or until radiographic union 3

Monitoring and Follow-up

• Regular radiographic follow-up to assess fracture healing
• Early diagnosis and appropriate treatment are crucial to prevent complications such as avascular necrosis, nonunion, malunion, and post-traumatic arthritis 1

Remember that early diagnosis and appropriate treatment based on fracture classification are essential to prevent long-term complications and optimize functional outcomes.